Rates of women who are opting for preventive mastectomies, such as Angeline Jolie, have increased by an estimated 50 percent in recent years, experts say. But many doctors are puzzled because the operation doesn't carry a 100 percent guarantee, it's major surgery -- and women have other options, from a once-a-day pill to careful monitoring.

What’s not so clear to the American Medical Association is what kind of incentives — and in what amounts — might encourage potential organ donors and their family members to follow through.

That’s why the AMA has waded into the controversial waters of offering financial incentives for cadaver organ donations, a proposition that can’t even be examined without modifying the National Organ Transplantation Act.

That’s the 1984 federal law that prohibits payment or any kind of “valuable consideration” for organ donation.

This month, the AMA voted to move forward with plans to amend the law to allow pilot studies to settle the incentive issue.

“We can speculate, but unless you actually study it, you don’t know,” said Dr. Joseph Annis, an AMA board member. “What’s standing in the way right now is NOTA.”

The federal law is aimed at preventing human organs from becoming a commodity, of course, said Dr. Gerald Wilson, a South Carolina surgeon and member of the AMA delegation that introduced the issue.

“People are concerned about the possibility that we’re buying organs,” Wilson said.

But even some of the harshest critics of payment for living organ donations — a separate hot-bed issue — say that studying incentives for donation after death should be acceptable in a nation where nearly 100,000 people remain on a waiting list for organs and nearly 10 percent die before a transplant becomes available.

Living donations raise most concern
“Those of us who worry about financial incentives corrupting organ donations worry most about living donations,” said David Rothman, director of the Center on Medicine as a Profession at Columbia University.

Rothman acknowledged that critics who oppose financial incentives for deceased donation fear that it's the first step on a slippery slope to payment for living organs.

Critics also worry that the prospect of even modest payments could lead patients' families to withhold vital medical information that could lead to rejection of an organ, or to prematurely withdraw care from a patient.

Ideally, the AMA hopes to determine whether cash contributions, payment for funeral expenses or even donations to a charity of the deceased’s choice might motivate family members to allow donation after death.

More than a decade ago, Pennsylvania approved a law to pay $300 toward funeral expenses for families of organ donors, but the rule was never enacted because of the NOTA restrictions.

The number and design of studies and where they might be conducted is not clear, Annis and Wilson said. Wilson, however, noted that the an organ procurement agency in his state, Life Point Inc. of South Carolina, may be interested in conducting a pilot study.

It’s not the first time this issue has been raised. The AMA first argued for studying motivations for cadaveric organ donation in 2002. The issue has been the subject of heated debates since then, both inside and outside the organ donation community.
The United Network for Organ Sharing, or UNOS, the nation’s organ allocation agency, is divided on the issue, said Dr. Benjamin Hippen, a North Carolina kidney transplant specialist.

‘It definitely doesn't go far enough’
Hippen, a member of UNOS ethics committee, believes in incentives for living and deceased donors alike and said the AMA’s intent to study the issue is only a necessary first step.

Efforts to increase cadaver donations actually have succeeded, he said. In the past five years, the percentage of deceased people eligible to donate organs who actually do so has risen from about 50 percent to nearly 70 percent, according to UNOS. In some places, the percentage may be even higher.

“It begs the question: If you’ve only got 20 percent more you get organs from, is it 20 percent who could be swayed? “ Hippen said.

Only well-conducted studies can answer that question. AMA officials said they’re not sure when they’ll begin serious lobbying to change NOTA, certainly not before a new president takes office.

"The politicians have their hands full," Annis said.

Meanwhile, critics like Rothman welcome a cautious approach.

"Would I line up to oppose this bill? No," he said. "Would it worry me? Yes."